Cost-effectiveness analysis of adding tuberculosis household contact investigation on passive case-finding strategy in Southwestern Uganda

Introduction The standard passive case-finding strategy implemented by most developing countries is inadequate to detect new cases of Tuberculosis. A household contact investigation is an alternative approach. However, there is limited cost-effectiveness data to support planning and implementation in low and middle-income countries. The study aimed to evaluate the cost-effectiveness of adding household contact investigation (HCI) to the passive case-finding (PCF) strategy in the Tuberculosis control program in Southwestern Uganda. Methods We conducted an economic evaluation using a retrospective study approach and bottom-up costing (ingredients) techniques. It was a synthesis-based evaluation of existing data extracted from the District Health Information System (DHIS 2), TB registers, and a primary cost survey. The study compared two methods of Tuberculosis (TB) case finding (PCF and HCI) strategies. Regarding PCF, patients either self-reported their signs and symptoms or were prompted by healthcare workers. At the same time, HCI was done by home visiting and screening contacts of TB patients. Patients and household contacts presumed to have Tuberculosis were requested to produce samples for analysis. We applied a static decision-analytic modeling framework to examine both strategies’ costs and effectiveness. The study relied on cost and probability estimates from National Tuberculosis (TB) program data, activity costs, and published literature. It was performed from the societal and provider perspectives over 1.5 years across 12 facilities in Ntungamo, Sheema, and Rwampara Districts. The primary effectiveness measure was the number of TB cases detected (yield) and the number needed to screen (NNS). The TB yield was calculated from the number of patients screened during the period under study. The incremental cost-effectiveness ratio (ICER) was expressed as cost in 2021 US$ per additional TB case detected. We did not apply a discount rate because of the short analytic time horizon. Results The unit costs of detecting a Tuberculosis case were US$ (United States dollar) 204.22 for PCF and US$ 315.07 for HCI. Patient and caregiver costs are five times more in PCF than in HCI [US$26.37 Vs. US$ 5.42]. The ICER was US$ 3,596.94 per additional TB case detected. The TB screening yields were 0.52% (1496/289140) for passive case finding and 5.8% (197/3414) for household contact investigation. Household contact investigation yield among children 0–14 Vs. 15+ years [6.2% Vs.5.4%] P = 0.04. The Yield among People living with HIV (PLHIV) Vs. HIV-negative [15.8% Vs.5.3%] P = 0.03 in HHCI. The PCF yield in men Vs. Women [1.12% Vs.0.28%] P<0.01. The NNS in PCF was 193 [95% CI: 186–294] and 17 [95% CI: 14–22] in HCI. Conclusion Our baseline assumptions and the specific implementations of adding HCI to existing PCF programs in the context of rural African settings prove to be not cost-effective, rather than HCI as a strategy. HCI effectively identifies children and PLHIV with TB and should be prioritized. Meanwhile, the Passive case-finding strategy effectively finds men with TB and costs lower than household contact investigation.

I will answer any questions you may have, and after you have decided to participate in the survey, you will be requested to sign a consent, and a copy availed you to keep.Your participation in this study is voluntary, and if you choose to withdraw from the study at any point, your information will be deleted and not used at any point in the data analysis and write-up

A brief description of the sponsors of the research project
It is academic research, and there is no sponsor for the project.

Purpose:
The study compares the cost-effectiveness of active household contact investigation and passive case finding in rural and periurban settings in South Western Uganda.The findings will provide evidence for informed policy decisions and improved practice of TB case findings.The study findings and recommendations shall be helpful to all stakeholders, including local governments, MoH, and NGOs involved in TB prevention and control.Last but not least, it is an academic research study as partial fulfillment of the requirement for the Master of Public Health Lira University award.It shall add to the existing pool of knowledge on cost-effectiveness studies in Uganda.

Procedures:
You will be asked several questions about the costs you spent while coming and waiting for the result of your current TB diagnosis.You are free to decline to answer any questions you do not want to answer.
I will read the questions to you about transport fees, food, and drinks expenses.Other indirect costs you incurred during travel time, waiting time, and absence from work will be asked.You will also be asked about the costs if you come with a caregiver.

Who will participate in the study?
You have been chosen to participate in this study because you were diagnosed and getting Tuberculosis treatment from this facility.The interview will last for approximately 30 to 45 minutes, and three of your colleagues will also participate in a similar study.

Risks/discomforts:
There is no foreseeable risk of harm or discomfort that will arise from your participation in this study.The only risk or discomfort will be the inconvenience in terms of time spent during the interview.

Benefits:
By taking part in this research study, you will help the study personnel to identify TB case finding methods with the most nominal costs and are easy to implement.You will be given health education on your treatment adherence and referred to a doctor if you are not feeling well due to the side effects of your medications.
The study information will also help the Ministry of Health officials in Uganda plan better TB/ HIV control programs for many similar communities in Uganda, which may benefit society in the future.

Confidentiality:
Your identity will not be revealed to anyone, as I shall only use codes to identify participants.Information obtained will only be accessible by the research team.The principal investigator will use a password to protect soft copies of the data and hard documents kept under lock and key.Only the principal investigator will have access to your confidential information.

Alternatives:
You do not have to participate in this study if you are not interested, and if you choose to withdraw from the study, your information will be deleted and not used at any point in the data analysis and write-up.You will not lose any benefit in case of no participation.

Costs:
There will not be any additional cost incurred as a result of participating in this study.

Questions:
If you have any questions related to the study as a research participant, you can contact the principal investigator, Odongo Dickens, on telephone number 0774 377545 or via email at dodongo1980@gmail.com

Statement of voluntariness:
Participation in the research study is voluntary, and you may join of your own free will.and if you choose to withdraw from the study at any point, your information will be deleted and not used at any point in the data analysis and write-up

A brief description of the sponsors of the research project
It is academic research, and there is no sponsor for the project.

Purpose:
The study compares the cost-effectiveness of active household contact investigation and passive case finding in rural and periurban settings in South Western Uganda.The findings will provide evidence for informed policy decisions and improved practice of TB case findings.The study findings and recommendations shall be helpful to all stakeholders, including local governments, MoH, and NGOs involved in TB prevention and control.Last but not least, it is an academic research study as partial fulfillment of the requirement for the Master of Public Health Lira University award.It shall add to the existing pool of knowledge on cost-effectiveness studies in Uganda.

Procedures:
You will be asked about your expert experiences from the health care professionals (Medical doctors, Clinical officers, nurses, laboratory personnel, cough monitors/T.B., the linkage facilitators) working on Tuberculosis infection prevention, care, treatment, and control.You are free to decline to answer any questions you do not want to answer.I will read the questions about health professional time, labor costs across the TB finding, supplies, equipment, Tests, training costs.

Who will participate in the study?
You have been chosen to participate in this study because you are a knowledgeable stakeholder in TB healthcare service delivery planning, implementation, and evaluation.The interview will last for approximately 45 -60 minutes, and eleven of your colleagues will also participate in a similar study.

Risks/discomforts:
There is no foreseeable risk of harm or discomfort that will arise from your participation in this study.The only risk or discomfort will be the inconvenience in terms of time spent during the interview.

Benefits:
By taking part in this research study, you will help the study personnel to identify TB case finding methods with the most nominal costs and are easy to implement.The study information will help the Ministry of Health officials and Local Government and implementing partners in Uganda plan better TB/ HIV control programs for many similar communities in Uganda, which may benefit society in the future.

Confidentiality:
Your identity will not be revealed to anyone, as I shall only use codes to identify participants.Information obtained will only be accessible by the research team.The principal investigator will use a password to protect soft copies of the data and hard documents kept under lock and key.Only the principal investigator will have access to your confidential information.

Alternatives:
You do not have to participate in this study if you are not interested, and if you choose to withdraw from the study, your information will be deleted and not used at any point in the data analysis and write-up.You will not lose any benefit in case of no participation.

Costs:
There will not be any additional cost incurred as a result of participating in this study.

Questions:
If you have any questions related to the study as a research participant, you can contact the principal investigator, Odongo Dickens, on telephone number 0774 377545 or via email at dodongo1980@gmail.com

Statement of voluntariness:
Participation in the research study is voluntary, and you may join at your own free will.
REC application number assigned to the research should be cited in any correspondence with the REC of record. 7.You are required to register the research protocol with the Uganda National Council for Science and Technology (UNCST) for final clearance to undertake the study in Uganda.The following is the list of all by student at Lira University pursuing a Master of Public Health and conducting research on the costs of Tuberculosis diagnosis.This informed consent explains the study to you.After the survey presentation, You have a right to withdraw from the study at any time without penalty.If you have any issues about your rights and participation in the study, don't hesitate to get in touch with the Chairperson, Gulu University Research Ethics Committee, Dr. Gerald Obai Tel: No., 0772305621; email: lekobai@yahoo.com/lekobai@gmail.com;or the Uganda National Council for Science and Technology, on plot 6 Kimera Road, Ntinda, Kampala on Tel 0414705500.Statement of consent ........................................................................... has described to me what is going to be done, the risks, the benefits involved, and my rights as a participant in this study.I understand that my decision to participate in this study will not affect me in any way.In the use of this information, my identity should be concealed.I am aware that I may withdraw during the study, and my information will be deleted and not used at any point in the data analysis and write-up.By signing this form, I understand that I do not waive any of my legal rights.Still, I merely indicate that I have been informed about the research study in which I voluntarily agree to participate.I will be provided with a copy of this form.Name ………………………… Signature of participant…………………….Date……………… Name………………………….Signature of interviewer…………………….Date………………